Health inspection·November 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few area, notified family, NP and Administrator. Injuries observed at time of incident: None, Level of Pain: zero. Witness: CNA C. Record review of Resident #2's Progress notes indicated the following: -On 10/31/23 at 10:13am; completed by LVN E: Resident #2 notified nurse that she had a burn from spilling her coffee on her abdomen, measurement 7x12 cm, red in color, small blister 0.5x 1cm. N/O for cold moist compress as needed and Silvadene burn cream QD until resolved. -On 10/31/23 at 10:36am; completed by NP F: Resident #2 showed NP burn. NP agreed with the nurse assessment and gave orders for cold compresses as needed for comfort and Silvadene daily until healed. NP will re-eval on Thursday when in the building. During an interview and observation on 11/3/23 at 5:58 p.m., Resident #2 was in her room lying in bed eating dinner meal. She said the morning of the incident CNA C spilled Resident #2's hot coffee while trying to move the overbed table closer to Resident #2. Resident #2 said she felt like her stomach was burning and the facility was treating her burn with an ointment and bandage until healed. At 6:00pm the Charge nurse came in Resident #2's room to change Resident #2's bandage. Observed Resident #2's stomach there was visible red to color blisters. The Charge Nurse treated Resident #2's burn with Silvadene burn cream and applied a clean bandage burn. During a phone interview on 11/14/23 at 3:26 p.m., CNA C said she was setting up Resident #2's breakfast meal tray and was trying to move the tray closer to Resident #2 and the hot cup of coffee spilt onto Resident #2's abdomen. She said she immediately removed Resident #2's shirt to assess the burn, and then notified a nurse. CNA C said she had never injured a resident before and spilling the cup of coffee on Resident #2 was a terrible accident. CNA C said she was not suspended and was in-serviced on facility's guidelines for serving coffee and in-service on hot liquids. During an interview on 11/3/23 at 5:49 p.m., the Administrator said she was the abuse coordinator. She said they had 2 hours to report to the State allegation or suspicion of abuse/neglect and for all other allegations they had 24 hours to report to the state. The Administrator said she was aware of the incident that occurred on 10/31/23 regarding CNA C spilling hot coffee on Resident #2's abdomen, resulting in burn/blisters. The administrator said the incident happened on 10/31/23 and she reported the incident to the State on 11/2/23. She said she should had reported the incident within two hours of the incident on the same day, but she was busy with another incident and forgot about it. She said she seen a note on her desk, and she realized she never called the incident in to the State and that was why it was late, and it was all on her not anyone else fault. Record review of intake worksheet created and received on 11/02/23 indicated: Date and time of the incident 10/31/23 at 8:00am; Date facility first learned of incident 10/31/23 at 10:00am. Immediate action taken to protect client: Temperature of coffee was checked and in range per policy. Hot Liquid Assessment was completed on all residents and safety interventions put in place as indicated. Staff in-service initiated regarding coffee service and reporting hot spills. Narrative of the incident: CNA C was serving Resident #2 her breakfast tray and accidently spilled some coffee on Resident #2 abdomen. Resident #2 reported to nurse that she got burned from the coffee. Resident #2 had small red area with small blister. Actions and Notifications: Nurse asked CNA C about the incident, and she reported the same information Resident #2 provided. Nurse obtained order to treat the burn. NP was on site and assessed as well. Physician and family were notified. Allegation: Neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of revised Abuse and Neglect policy dated 3/29/18 indicated It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.A. Reporting: 3.Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. Event ID: Facility ID: 675105 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents. (Resident #2) The facility failed to provide adequate supervision during breakfast meal which resulted in CNA C spilling hot coffee on Resident #2 abdomen and Resident #2 sustained blisters from the coffee. This failure could result in residents who drank coffee at risk of having burn accidents, pain, and a diminished quality of life. Findings included: Record review of Resident #2's face sheet, printed on 11/3/23, indicated she was a [AGE] year-old female who admitted to facility on 11/03/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis due to having a stroke), cerebral infarction due to embolism of right middle cerebral artery (stroke occurs when blood flow from the middle cerebral artery, one of the largest arteries of the brain, is suddenly interrupted (ischemia ) or altogether stopped (infarction ). The loss of blood flow causes tissue death, leading to serious and potentially permanent brain injury), and dysphagia (the medical term for swallowing difficulties). During an interview and observation on 11/3/23 at 5:58 p.m., Resident #2 was in her room lying in bed eating dinner meal. She said the morning of the incident CNA C spilled Resident #2's hot coffee while trying to move the overbed table closer to Resident #2. Resident #2 said she felt like her stomach was burning and the facility was treating her burn with an ointment and bandage until healed. At 6:00pm the Charge nurse came in Resident #2's room to change Resident #2's bandage. Observed Resident #2's stomach there was visible red to color blisters. The Charge Nurse treated Resident #2's burn with Silvadene burn cream and applied a clean bandage burn. During a phone interview on 11/14/23 at 3:26 p.m., CNA C said she was setting up Resident #2's breakfast meal tray and was trying to move the tray closer to Resident #2 and the hot cup of coffee spilt onto Resident #2's abdomen. She said she immediately removed Resident #2's shirt to assess the burn, and then notified a nurse. CNA C said she had never injured a resident before and spilling the cup of coffee on Resident #2 was a terrible accident. CNA C said she was not suspended and was in-serviced on facility's guidelines for serving coffee and in-service on hot liquids. Record review of Resident #2's quarterly MDS dated [DATE] indicated she had clear comprehension and made herself understood. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated she had moderately impaired cognition. Resident #2 required setup or clean-up assistance with eating and required substantial/maximal assistance with upper body dressing and dependent with shower/baths, lower body dressing, putting on/taking off footwear and dependent with personal hygiene. Record review of Resident #2's incident burn/blister report dated 10/31/23 completed by LVN E indicated the incident happened in Resident #2's room. Incident Description: Nursing Description - Went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few into Resident #2's room to administer morning medications and Resident #2 pointed out she had a burn from her coffee on her upper central abdomen, 7 x12 cm. Resident Description - Resident #2 stated I think CNA C accidently hit the cup closest to her and it spilt on her. Resident #2 was lying in bed with her eyes closed. CNA was as startled as her. Immediate Action Taken: Applied cold compress to area, notified family, NP and Administrator. Injuries observed at time of incident: None, Level of Pain: zero. Witness: CNA C. Record review of Resident #2's Progress notes indicated the following: -On 10/31/23 at 10:13am; completed by LVN E: Resident #2 notified nurse that she had a burn from spilling her coffee on her abdomen, measurement 7x12 cm, red in color, small blister 0.5x 1cm. N/O for cold moist compress as needed and Silvadene burn cream QD until resolved. -On 10/31/23 at 10:36am; completed by NP F: Resident #2 showed NP burn. NP agreed with the nurse assessment and gave orders for cold compresses as needed for comfort and Silvadene daily until healed. NP will re-eval on Thursday when in the building. Record review of intake worksheet created and received on 11/02/23 indicated: Date and time of the incident 10/31/23 at 8:00am; Date facility first learned of incident 10/31/23 at 10:00am. Immediate action taken to protect client: Temperature of coffee was checked and in range per policy . Hot Liquid Assessment was completed on all residents and safety interventions put in place as indicated. Staff in-service initiated regarding coffee service and reporting hot spills . Narrative of the incident: CNA C was serving Resident #2 her breakfast tray and accidently spilled some coffee on Resident #2 abdomen. Resident #2 reported to nurse that she got burned from the coffee. Resident #2 had small red area with small blister. Actions and Notifications: Nurse asked CNA C about the incident, and she reported the same information Resident #2 provided. Nurse obtained order to treat the burn. NP was on site and assessed as well. Physician and family were notified. Allegation: Neglect. Record review of nursing policy and procedure: hot liquid/food spills dated 2003 indicated Residents are at risk of having any hot liquid/food spilled on their person causing burns. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance. Procedure: 1) If any staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. 2) The charge nurse is to be immediately notified so that an assessment of the resident can be completed. 3) The charge nurse will report any injury to the attending physician and responsible party and follow any further physician orders. 4) Staff will assist with changing of clothes as needed. 5) An incident report and investigation will then be completed and determine if the resident needs interventions to prevent future occurrences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 dosage because mediation was not available. Level of Harm - Immediate jeopardy to resident health or safety During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Residents Affected - Few Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on [DATE] at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on [DATE] 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric hospital on [DATE] after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Interventions: Level of Harm - Immediate jeopardy to resident health or safety *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. Residents Affected - Few *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The DON/designee will review new pharmacy orders 5 days per week to ensure medications are available to be administered as ordered. The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 10. Right evaluation Level of Harm - Immediate jeopardy to resident health or safety *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) Residents Affected - Few The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega dosage because mediation was not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on [DATE] at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on [DATE] 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric hospital on [DATE] after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. The DON/designee will review new pharmacy orders 5 days per week to ensure medications are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 available to be administered as ordered. Level of Harm - Immediate jeopardy to resident health or safety The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Residents Affected - Few Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 10. Right evaluation Level of Harm - Immediate jeopardy to resident health or safety *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryview Nursing & Rehabilitation 1900 N Frances St Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications were secured on 3 of 4 medication carts reviewed for pharmacy services. (500 Hall, 600 Hall and 800/900 Halls Medication Carts) - LVN B failed to ensure the Medication carts for 500 Hall and 600 Hall was not left unlocked, unsecured, and unattended. -DON failed to ensure the Medication cart for 800/900 Halls was not left unlocked, unsecured, and unattended. These failures could affect the residents, who received medications from those carts, by placing them at risk of drug diversions or misuse of medications. Findings included: During an observation on 11/3/23 at 4:46 p.m., revealed the 500 Hall medication cart and the 600 Hall medication cart was unlocked and unattended in front on the nurse station. All the drawers of the medication could be opened, and the medication was easily accessible. The cart was unattended for unknown amount of time. Residents were observed passing by the medication cart. During an interview on 11/3/23 at 4:49 p.m., LVN B was sitting behind the nurse station working on the computer. The State Surveyor pointed out the medication carts was left unlocked and unattended, and LVN B said the medication carts were never supposed to be left unlocked and she did not know why she did it, it was a mistake. During an observation on 11/14/23 from 2:17 p.m., to 2:29 p.m., revealed the 800/900 Halls medication cart was unlocked and unattended in front of the nurse station. All the drawers of the medication could be opened, and the medication was easily accessible. The cart was unattended for unknown amount of time. Residents were observed passing by the medication cart. During an interview on 11/14/23 at 2:29 p.m., the DON returned to nurse station with a bag of food items. The State Surveyor pointed out the medication carts was left unlocked and unattended. The DON said it was her fault and she was responsible for leaving the 800/900 hall medication cart unlocked. She said around noon the previous staff had an emergency and had to leave, she was filling in and working on the floor as a charge nurse. The DON said the medication carts were never supposed to be left unlocked and she didn't know why she did it, it was a mistake. Record review of pharmacy policy and procedure manual dated 2003: medication carts revealed 1) The medication carts shall be maintained by the facility. 2) The carts are to be locked when not in use or under the direct supervision of the designated nurse. 3) Carts not in use are to be stored in a designated area not blocking egress in the building. 4) Carts must be secured. 5) Carts should be clean. 6) Should said equipment be found unsuitable for use or in need of general maintenance. This equipment includes medication cart, administration records, notebooks, and Emergency Kits facility or designee will repair/replace. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675105 If continuation sheet Page 18 of 18